Dr. Lindsey's Newsletter #31: Plastic Surgery by Decade - 60s: The Upper Third

60s Continued: In Your Eyes - The Upper Third 

Last week we reviewed the features of facial aging at a very zoomed out, high level. There is so much more to learn about facial aging as it directly relates to surgical options to restore your face from whence it came. As a plastic surgeon I evaluate facial aging by dividing the face into horizontal thirds. There are aesthetic, genetic, and anatomic reasons why this makes sense. In this edition we will learn about the upper third of the face.

Your forehead and brows live in the upper third of the face. Features of aging in this region from top down include:

• Receding hairline
• Age spots
• Fine lines and/or deep wrinkles
• Drooping brows to the level of, or below your orbital rim (brow bone)

The Spectrum of Upper Third Surgery 

The surgical fix for an aged forehead and a drooping brow is a brow lift or a forehead lift. These terms are often used interchangeably for a toolbox of several different surgical approaches to raising the brows. Your surgical needs will depend on the degree of severity of your forehead wrinkles and how low your brow is. Before I can recommend a procedure I perform a careful evaluation of each patient’s individual anatomy. There is a spectrum of procedures that range from two smaller scars or one continuous scar. Your anatomy including the severity of wrinkles and brow droop will dictate which surgical procedure is needed.  I work with each patient to determine what is needed to achieve a powerful but natural appearing result. 

Gravity can be quite cruel because not only does each part of your face suffer from the pull of gravity, but your upper eyelids are directly affected by the weight of gravity upon your brow. The crows feet region is also made heavier from this weight and you may have excess skin bunching around your eyes. Because of this dynamic interplay of the upper third and middle third, it is difficult for patients to decipher on their own whether or not they need a brow lift or an eyelid lift. An expert examination by a plastic surgeon is important to evaluate the anatomy, the interplay of the horizontal thirds, and only by physical exam can a proper surgical plan be formed. 

“Doctor, why can’t I just have my eyelids done?”

It is quite common for patients to request eyelid lift surgery when the real problem is a drooping brow (brow ptosis). Once the brow is lifted, skin that appeared to be redundant in the upper eyelid often disappears as it is recruited back up to where it belongs. In these cases, the problem was never excess eyelid skin, it was always a low brow that pushed down on the eyelids and created redundant skin rolls.

Goals of a forehead/brow lift: 

• Raise the brows to the proper position
• Reduce the appearance of forehead wrinkles 
• Remove the sagging brow skin from over the eyelids, improving their appearance

Forehead lifts can be one of the most daunting surgeries for my patients to sign up for fear of scars and an unnatural appearance.  You can rest assured that the surgery is powerful and natural appearing. The eyes appear brighter with more visible eyelid skin, the wrinkles in the forehead are no longer apparent. And most importantly, you will look natural.

How Long is Your Forehead?

When I evaluate my surgical patients I perform a facial analysis of the aesthetic proportions. If you have a forehead that is long compared to the other horizontal thirds then I place my scar in a way to also lower the hairline and reduce the size of your forehead. A second benefit of this scar placement is if you have a triangular receding hairline, this can sometimes be excised and advanced for better hair density along your hairline. 

Other Tools in My Upper Third Toolbox

The purpose of this newsletter is to focus on surgical interventions for the upper third but there are a few other key tools for upper third rejuvenation. My favorites are:

• PRP injections + Microneedling - this combination is used along the hairline to stimulate hair growth in both men and women.
• Tox injections - while a neurotoxin injection (like Dysport) can smooth your forehead wrinkles, it is so important for your injector to understand the dynamics of facial aging otherwise a tox injection could make your upper third appear worse.
• Skincare - I will never get off this soapbox, if you don’t take good care of your skin then you will never maximize your results. Anti-aging measures start with medical grade skincare.